Non-Suicidal Self-Injury: Therapeutic Approaches

This article summarises recent empirical findings about what therapeutic approaches and treatment elements work best to reduce the self-harm of NSSI.

Related reading: Non-Suicidal Self-Injury: Aetiology, Non-Suicidal Self-Injury: Context, Forms and Functions, Non-Suicidal Self-Injury: Prevalence, Risk and Protective Factors.

Introduction

Non-suicidal self-injury, or NSSI, alarms mental health professionals and researchers because, even though the person harms themselves without intent to die, they can hurt themselves more seriously than intended and the behaviour is a strong risk factor for later suicidal attempts. This is the last article in our series of four on NSSI, with previous articles discussing: (1) the forms and functions of NSSI; (2) the prevalence, risk/protective factors and warning signs; and (3) the aetiology of NSSI, including an outline of the psychological, social, and neurobiological factors. Today we offer a summary of the missing piece: the therapeutic approaches and treatment considerations that are most likely to reduce self-harm.

A search of over 126 million academic papers from the Semantic Scholar corpus retrieved the 50 papers most relevant to the question: “What are currently deemed to be the most efficacious methods of dealing with self-harm?”.  The results yielded two strands: a recapitulation of the therapeutic approaches often utilised (and studied); and implementation considerations, which related mainly to professional attributes, service delivery factors, and client engagement elements. Here is a brief summary of what research has found.

Therapeutic approaches

We note here that, while other therapies may well be phenomenal in reducing self-harm in some cases, we only include those that have been empirically tested. Thus, we echo the plea for more research in this area. Not surprisingly, the gold-standard (and most researched) therapies of CBT and DBT came up trumps.

Cognitive behavioural therapy (CBT) and dialectical behaviour therapy (DBT)

There is moderate quality evidence from multiple systematic reviews and randomised controlled trials, which indicated reductions in self-harm repetition or frequency and related symptoms. Effect sizes were generally small to moderate. Replication of positive impact was noted for both interventions. These two therapies, or some variation on them, are most frequently cited as interventions that work (Slee et al, 2008; Iyengar et al, 2018; Kothgassner et al, 2020; Hawton et al, 2016a; Hawton et al, 2016b).

Family-centred therapy and mentalisation-based therapy

Some studies reported moderate effects, particularly for suicidal ideation, but evidence was less frequently replicated and often limited by small sample sizes, which limits generalisability.

Case management and remote contact interventions

In these studies, no significant benefit for reducing self-harm repetition was reported. This is not to say that these approaches do not assist in the reduction of self-harm, but future research may show that they help more as adjunctive therapies than stand-alone methods (Slee et al, 2008; Iyengar et al, 2018; Kothgassner et al, 2020).

Pharmacotherapy

Limited and unquantified evidence was found, with no general support for use except possibly in specific psychiatric populations. Thus, a client who is dealing with, say, depression as well as self-harm, may be helped by medication with the depression, with the improved mood possibly making it easier for the client to reduce some of the self-harm. Much more research is needed here (Hawton et al, 1998).

Implementation considerations

Importantly, some of the factors which mattered as much as the therapeutic approach taken were those of the quality of support the client received, the nature of the service delivery, and factors related to client engagement.

Professional support attributes

The therapeutic alliance overall. No controversy surrounds the findings that, across studies, clients valued therapists and other professionals with whom they could have a strong, reciprocal, non-judgmental, and empathic relationship. This was perceived as central to effective support, regardless of the specific therapeutic model the therapist used, with some meta-studies showing that 80% of the variance in outcomes can be attributed to the therapeutic alliance.

Direct and confident. Study subjects also responded positively to professional confidence and directness. In previous articles, we have debunked the myth that, by asking someone directly about whether they had thought about harming themselves, the client is given the idea toperpetrate self-harm. Rather, the opposite is true. When professionals demonstrate their ability to confidently address self-harm directly, they provide a safe space for discussion. This was highlighted as a key attribute.

Timeliness and reliability. Few clients like cooling their heels in the therapist’s outer office or worse, trying to contact the therapist during an emergency and finding that there is zero support outside of regularly scheduled session times. Timely, reliable, and consistent support was considered critical for client engagement and positive outcomes (Sass et al, 2022; Ougrin et al, 2012).

Service delivery factors

Continuity of care. While being able to continue with the same therapist was not consistently associated with reduced repetition of self-harm, studies indicated that it may enhance engagement. At the very least, the therapist can access an engaged client to continue the therapy until self-harm is reduced, so it is possible that continuity of care has an indirect effect on self-harm.

Dropout and engagement. Conversely, when clients drop out of therapy prematurely, the effectiveness of the interventions is limited as is the strength of the evidence when the therapy is part of a research trial. High dropout rates and poor follow-up were common in the studied investigations, pointing to a need for greater therapeutic attention to this aspect.

Cultural and contextual fit. How well does a client’s treatment, and how it is delivered, align with the client’s culture and the context in which it occurs? Most of the evidence was from high-income countries and predominantly female samples, which may limit generalisability. In light of the prevalence data showing how widespread self-harm is, within Australia and the U.S. and also globally, we do not have the luxury of adhering to the myth that self-harm is a “girl thing”, occurring in only middle- or upper-class families. As noted, where there is cultural stigma regarding discussion of mental health issues generally or self-harm and suicide specifically, professionals must take care to use therapeutic approaches which respect the cultural framework of the client while moving them away from NSSI as a solution to their issues (Asarnow & Mehlum, 2019; Boyce et al, 2003).

Client engagement elements

Individualisation. Interventions tailored to the individual’s needs, motives, and experiences of self-harm were valued in the reviewed studies. A client trying to get relief from negative emotions has a different motivation than one who self-harms to counter dissociation. Likewise, a client who is cutting may need different distracting (e.g., “fake” self-harm techniques) than someone who has been banging their head against walls. Issues of comorbidity also come into play as part of the individualisation that heightens engagement, as those with externalising comorbid conditions (e.g., aggression) will benefit from different interventions than those with, say, an eating disorder or an internalising condition, such as depression.

Family and systems involvement. Family-centred and systems-based approaches may enhance outcomes, especially in adolescents. When the whole family participates, the opportunity exists to gently re-align family dynamics to understand the whole family system, rather than the self-harming behaviour of one member, as “the problem”. Parents and siblings can be helped to learn how to support the self-harming member in ways that meet the needs the self-harming client is trying to meet through the NSSI. We reiterate that research showed family and systems involvement as a positive for client engagement rather than direct findings that bringing in family members reduced self-harm.

Barriers to engagement. Stigma, lack of trust, and poor therapeutic alliance were identified as barriers to effective support. Here we should note yet again that some communities – especially minoritised ones and those comprised of other than mainstream cultural members – do not have the experience of therapy being a “safe” or helpful thing to do. The difficulty in engaging, research shows, translates to difficulty shifting the self-harm behaviour to that which meets the unmet needs in more adaptive ways (Asarnow & Mehlum, 2019; Boyce et al, 2003).

Conclusion: Synthesis of the findings

We can summarise these findings by noting that two major points stand out from the studies:

• Interventions such as CBT and DBT have moderate evidence for reducing self-harm repetition or frequency; and
• The quality of the therapeutic relationship and individualised, empathic care are consistently highlighted as central to positive outcomes.

Thus, implementation should focus on the choice of intervention and also on professional attributes, engagement strategies, and contextual and cultural fit. As any mental health professional who has worked with self-harming clients can attest, reducing NSSI is supremely difficult work. But by working in alignment with this research, the therapist can ultimately help a client shift from the maladaptive position of having only self-injury as a solution to their problems to seeing a range of healthy options for making life better.

Key takeaways

• Multiple systematic reviews and randomised controlled trials offered moderate quality evidence that CBT and DBT approaches reduced self-harm repetition or frequency.
• Most other therapies were either not studied or offered weak, sometimes inconsistent, findings as efficacious for reduction of NSSI behaviours; some may work as adjunctive therapies rather than standalone ones.
• Implementation considerations showed most strongly the importance of a solid therapeutic alliance, through which the professional could support the client directly and reliably.
• Service delivery factors related to continuity of care and contextual/cultural fit.
• Client engagement strategies were deemed important, and these revolved around individualisation of treatment regimen, involvement of family, and working through barriers to engagement.

Questions therapists often ask

Q: Which therapies currently have the strongest empirical support for reducing non-suicidal self-injury (NSSI)?

A: Evidence is strongest for Cognitive Behavioural Therapy (CBT) and Dialectical Behavior Therapy (DBT). Multiple systematic reviews and randomized controlled trials show that these approaches can reduce the frequency or repetition of self-harm, with small to moderate effect sizes.

Q: Are family-centred or relationship-based therapies useful for NSSI treatment?

A: There is some evidence — though more limited and less consistently replicated — suggesting that family-centred therapy and Mentalization-Based Therapy (MBT) may help, especially where suicidal ideation is a concern. However, small sample sizes and inconsistencies reduce confidence about their general efficacy.

Q: Can simpler approaches like case-management or remote (phone/online) contact replace formal therapies for reducing NSSI?

A: Research reviewed in the article found no significant benefit from case-management or remote-contact interventions in reducing self-harm repetition when used alone. These are not shown to be reliable standalone treatments, though they might still serve as adjunctive supports.

Q: Does use of psychotropic medication directly reduce NSSI behaviours?

A: The evidence for pharmacotherapy is very limited and does not support medication as a primary treatment for NSSI. Medication might help if an individual has comorbid conditions (like depression), but medication alone is not a proven strategy to reduce self-injury.

Q: Beyond the choice of therapeutic model, what therapist or service-delivery factors matter most for successful NSSI treatment?

A: A strong therapeutic alliance — empathic, nonjudgmental and direct — is critical. Equally important are timely and reliable access to support, continuity of care, culturally/contextually appropriate treatment, individualised tailoring of interventions, and involving family or systems when relevant. These factors often matter as much or more than which therapy is used.

References

• Asarnow J, and Mehlum L. (2019). “Practitioner Review: Treatment for Suicidal and Self-Harming Adolescents – Advances in Suicide Prevention Care. Journal of Child Psychology and Psychiatry and Allied Disciplines, 2019.
• Boyce P, Carter G, Penrose-Wall J, Wilhelm K, and R. Goldney R. (2003). Summary Australian and New Zealand Clinical Practice Guideline for the Management of Adult Deliberate Self-Harm (2003).
• Hawton K, Arensman E, Townsend E, Bremner S, Feldman E, Goldney R, Gunnell D, et al. (1998). Deliberate Self Harm: Systematic Review of Efficacy of Psychosocial and Pharmacological Treatments in Preventing Repetition. British Medical Journal, 1998.
• Hawton K, Witt K, Salisbury T, Arensman E, Gunnell D, Hazell P, Townsend E, and van Heeringen K. (2016a), Psychosocial Interventions Following Self-Harm in Adults: A Systematic Review and Meta-Analysis. Lancet Psychiatry, 2016a.
• Hawton K, Witt K, Taylor TL, Salisbury T, Arensman E, Gunnell D, Hazell P, Townsend E, and van Heeringen K. (2016b), Psychosocial Interventions for Self-Harm in Adults.” Cochrane Database of Systematic Reviews, 2016b.
• Iyengar U, Snowden N, Asarnow J, Moran P, Tranah T, and Ougrin D. (2018), A Further Look at Therapeutic Interventions for Suicide Attempts and Self-Harm in Adolescents: An Updated Systematic Review of Randomized Controlled Trials. Frontiers in Psychiatry, 2018.
• Kothgassner O, Robinson K, Goreis A, Ougrin D, and Plener P. (2020). Does Treatment Method Matter? A Meta-Analysis of the Past 20 Years of Research on Therapeutic Interventions for Self-Harm and Suicidal Ideation in Adolescents. Borderline Personality Disorder and Emotion Dysregulation, 2020
• Ougrin D, Tranah T, Leigh E, Taylor L, and Asarnow J. (2012), Practitioner Review: Self-Harm in Adolescents. Journal of Child Psychology and Psychiatry and Allied Disciplines, 2012.
• Sass C, Brennan C, Farley K, Crosby H,  Lopez RR, Romeu D, Mitchell E, House A, and Guthrie E. (2022). “Valued Attributes of Professional Support for People Who Repeatedly Self‐harm: A Systematic Review and Meta‐synthesis of First‐hand Accounts.” International Journal of Mental Health Nursing, 2022.
• Slee N, Garnefski N, van der Leeden R, Arensman E, and Spinhoven P. (2008). Cognitive-Behavioural Intervention for Self-Harm: Randomised Controlled Trial. British Journal of Psychiatry, 2008.